Wednesday, July 22, 2009

Womyn of the Week - Arlene Istar Lev and Her Thought-Provoking Article, "Feminism and Psychiatric Diagnosis"

Much is written about mental illness, but alas, rarely from a feminist perspective.

I found this article online and found it to be thought-provoking and well-written and wanted to share it. The article is written by Arlene Istar Lev, LCSW, CASAC, is a social worker, family therapist, educator, and writer whose work addresses the unique therapeutic needs of lesbian, gay, bisexual, and transgender people. She is the founder of Choices Counseling Associates in Albany, New York, providing family therapy for LGBT people. She is also on the adjunct faculties of S.U.N.Y. Albany, School of Social Welfare, and Vermont College of the Union Institute and University. She is the author of The Complete Lesbian and Gay Parenting Guide (Penguin Press, 2004) and Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families (Haworth Press, 2004). Additionally, she maintains a “Dear Ari” advice column, which is currently published in Proud Parenting and Transgender Tapestry. She is also the Founder and Project Manager for Rainbow Access Initiative, a training program on LGBT issues for therapists and medical professionals, and a Board Member for the Family Pride Coalition. Her “In a Family Way” column on LGBT parenting issues is nationally syndicated. She is an activist, a writer, a gardener and a mom. Lev is Sundance's partner, and Shaiyah's momma.

This article is in response to a previous one published in The Women's Building News and I regret that I could not find the issue that she is addressing.****************************************

As a feminist therapist, I found the last issue of The Women's Building News on mental illness as a feminist issue to be well-written and timely. I thought Janet Chassman's article was an excellent overview of many of the issues, and the coverage of both cultural diversity and legal issues to be important areas to examine. Despite the cover title, "The Last Closet", may I dare to suggest that there are still many many closets left to open in our feminists communities, and though issues of psychiatric disabilities is one of them, it is certainly not the "last."

Focusing on the treatment of women within the psychiatric system is an important issue, however, I must admit to being somewhat surprised by the lack of critique of the psychiatric system in general. The absence of any discussion regarding the use of language and labeling as a feminist mental health issue -- including such terms as "mental illness" and "psychiatric disorder" -- was glaring in its absence. The psychiatric profession is permeated by Eurocentric, patriarchal, racist, sexist, and homophobic thinking that has done enormous damage to the mental health of women, children and people of color.

The psychiatric profession has developed a manual to label mental illnesses. This document, The Diagnostic and Statistical Manual of Mental Disorders, called the DSM, is in its fourth revision, and is extremely controversial in a number of ways. In my role as a Social Work educator, I teach Master's level students how to utilize the DSM; as a feminist and holistic practitioner I also teach them to be very wary of labeling. The DSM is the primary tool used by the managed care system to determine insurance reimbursement, and eligibility for disability determinations; it is often utilized in legal settings and educational institutions. To paraphrase Audre Lorde's eloquent statement, "Can we tear down the master's house using the master's tools?"

Diagnosis is a political tool. It has been used to medicate angry and powerless women and to take away our children. It has been used to hospitalize political activists and other radicals. In the not very distant past women were routinely diagnosed with Hysteria, and treated with clitorectomies! In the latter part of the 1800's African slaves were diagnosed with drapetomania, which was believed to be a blood disorder, and according to the diagnostic texts, was "cured by whipping"!!! Benjamin Rush, the "father of modern psychiatry" believed that the reasons Africans had dark skin was because they had a form of leprosy which he called Negritude, and to the embarrassment of his biographers, worked diligently his whole life towards a "cure." Other medical textbooks list the size of men's heads to prove that people of African descent had smaller brains, and that people with larger noses (Semitic people) had certain communicable diseases. Homosexuality was considered a psychopathology until approximately 20 years ago, which meant that ALL gays, lesbians, and bisexuals were diagnosed with this "psychiatric illness."

If the above examples sound absurd, or irrelevant, remember that the removal of these diagnoses is only within the last 100-150 years, and as I will outline below, many current diagnoses are equally offensive. The popularity, utilization, and frequency of particular diagnoses changes with the seasons. Whether "illnesses" are viewed as biological, psychological, behavioral, or moral shifts back and forth throughout history. Behaviors that are considered "normal" in one country are considered "psychopathologies" in another. Diagnoses that are considered rare in one part of the country, are considered "rampant" in others.

For example, in the late 1880's upper class white women in England and the U.S. were diagnosed with Conversion Disorder whereas they would suddenly lose the ability to see or walk, without any known physical reason. Women also displayed symptoms of Hysteria -- manifested by fainting, yelling, and depressive "fits." It is interesting to note these illnesses, and behavior manifestations, are today extremely rare, and was considered rare then among poor women, women of color and women from other countries. Today women are commonly diagnosed with Borderline Personality Disorder and Multiple Personality Disorder (now Dissassociative Disorder).

It is clear to most therapists today, -- due to the powerful lobbying of feminist therapists over the last two decades --, that most of the above disorders are the results of trauma, most commonly physical and sexual abuse. Can the same illness manifest in different ways at different times? Do women who are traumatized by abuse, exhibit different symptomologies across class and racial lines? Can it be that human beings manifest certain symptoms in ways that are politically and socially acceptable within certain historical times? Certainly it cannot be true that only wealthy white women in Victorian England were being traumatized, but the symptom and behaviors of other women were not perceived as important, or perhaps poor women and women of color were not "treated" for medical problems, but punished by the penal system.

The DSM does not identify mental illnesses by their etiology (i.e. their causes) but rather by their effects. This means that if three women are sexually abused one might be labeled with depression ,one might be labeled with anxiety, and one might be labeled with bulimia, -- if those are the principal manifesting symptoms. The unhealthy ways a woman copes with the trauma becomes the avenue for diagnosis, instead of labeling the way she was victimized, or recognizing the healthy ways she has adapted in order to survive.

Changes in the DSM are not immune from political pressure. Some changes are beneficial, others more problematic. For instance some positive changes in the past 50 years include the shift from viewing Alcoholism as a moral problem to a medical one, the removal of Homosexuality from the DSM, and the utilization of Post-Traumatic Stress Disorder (PTSD) in treating victims and survivors of incest, domestic violence, and sexual assault.

Current trends that are more questionable include the labeling of children with Attention Deficit Disorder (ADD) and Gender Identity Disorder. The numbers of children labeled with ADD continues to rise yearly, -- young males, and particularly young African-American males are most often labeled. Are more children having attention problems now than they were 20 years ago, or has something else changed about our society, our school system, or perhaps how we view the normal energy of young males? Is it possible that something about the energy of young Black boys is so frightening to our society that we need to medicate it?

In the last issue it was stated that "1 in 5 children/adolescents may have a diagnosable mental disorder." Statistics like these frighten me, and I am left wondering who was the researcher who studied this social malady. Could it perhaps be the pharmaceutical companies, or perhaps, the administrators of psychiatric hospitals? As managed care has become more and more resistant to paying for services for adults, the concerns for young children have suddenly risen. Many managed care programs are willing to pay large sums of money to support the "care" of disturbed young people, and many psychiatric hospitals have suddenly re-focused their entire treatment programs on the care of young people. We cannot ignore the role that profit plays in the diagnosing and treatment of vulnerable populations.

One of the common "new" diagnoses that young people are given is Gender Identity Disorder. This diagnosis is for children whose behavior and manner deviate from the accepted socially sanctioned appropriate gender behavior of boys and girls. Since Homosexuality was removed from the DSM in 1973, this has become the new diagnosis for young gays and lesbians. It has been used to treat gender transgressive young people who are gay, transgendered and/or just plain rebellious with shock therapy, medications, and hospitalizations in some cases lasting for 5 and 6 years. Can you tell me that this is not feminist backlash? The psychiatric profession is an institutionalized arm of a sexist, heterosexist, and transphobic patriarchal system. Diagnosis, I repeat, is political.

In the last issue of Women's Building News, the word Depression was frequently used as a psychiatric label. I am aware that this is technically correct (i.e. Depression is listed in the DSM) and I am also aware that severe or chronic Depressions can be debilitating and disabling. However, most people do experience some depressive episodes in their lifetimes, and I would argue that, like colds and intestinal flues, they are a part of the ebb and flow of health and illness within a "normal" human lifecycle. Depressions require familial and perhaps therapeutic support -- and maybe even pharmacological support --, but calling it a psychiatric illness??? "Depressions" can also be times of transformational change in people's lives -- spiritually referred to as "dark nights of the soul", -- times of reflection and self-examination.

I want to be clear that I am not in anyway denying the pain that human beings experience or the horrible realities of addictions, depressions, behavioral disorders in children, or dissociation in trauma survivors. I have dedicated my life to working with people who are struggling with these realities. I am saying that it is not entirely clear to me what words like "mental illness", "mental health", "psychiatric disorder" -- or even words like "treatment" -- mean. I am saying that diagnoses have been used historically to hurt and repress women and children, homosexuals and bisexuals, people of color, people who are genderly "different", and that I am very very leery to use the language of that system without clearly asking what it means and to whom.

Feminism has taken the psychiatric profession to task in the last few decades questioning the overuse of psycho-pharmacological intervention, and questioning diagnoses like Co-dependency, Pre-Menstrual Syndrome, Battered Women's Syndrome, and Borderline Personality Disorder. I was surprised that in a feminist publication there was so little questioning of the institutional sexism of the psychiatric system, and only a focus on how the system can better serve women who are already victimized by it.

I believe that as feminists who care about the mental health of women, children, and those we love, we must look at the patriarchal system of labeling illness with some skepticism. We must, of course, dismantle the stigma attached to "mentally ill" people, and work toward humane treatment and adequate resources. However, we must also examine the mental health system as a tool of the patriarchy, and cease labeling human differences as psychopathologies. We must stop hiding behind psychiatric diagnoses and examine the realities of trauma, oppression and abuse on the lives of women and children.

*Everything in bold is my own emphasis.

**************Note: While I was looking up the pages for the links for this post, I found some really interesting stuff!

On Benjamin Rush: While studying psychiatry, Rush devised two curious instruments, the gyrator, based on the principle of centrifugal action to increase cerebral circulation, and the tranquilizer, "to obviate these evils of the 'strait waistcoat' and at the same time to obtain all the benefit of coercion". These instruments provided a form of shock therapy, which was interpreted as effecting cures according to his theory involving nervous states.Just reading the technical language for the diagnosis and treatment of Gender Identity Disorder made me want to hurl.

What Lev didn't mention was that one of the "cures" for Conversion Disorder, also known as "hysteria," was the use of a vibrator. These are ads from a 1918 Sears catalog. If only they were still sold at the store I frequent!

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I'm a fierce smashing-the-patriarchy Christian feminist spreading the word that hope is real for people with mental health and chronic pain challenges. I do NAMI In Our Own Voice presentations, endorse Dialectical Behavioral Therapy(DBT) and baking cupcakes. I am in recovery from borderline personality disorder, an eating disorder and bipolar II. I work on managing my anxiety. I consider myself living in recovery, because mental illness and chronic pain no longer control my life.
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